Early echocardiographic evaluation following percutaneous implantation with the self-expanding CoreValve Revalving System aortic valve bioprosthesis.

AIMS: Although safety and feasibility studies have been published, there are few reports dedicated to the echocardiographic evaluation of patients following percutaneous aortic valve replacement (PAVR). This report describes the early echocardiographic evaluation of patients undergoing PAVR with the CoreValve Revalving System. METHODS AND RESULTS: The population consisted of 33 consecutive patients with aortic stenosis who underwent successful PAVR. Echocardiograms were performed pre-treatment (123+/-110 days prior), post-treatment (6+/-2 days) and post-discharge (80+/-64 days). Aortic valve function and left ventricular dimensions, systolic and diastolic function were assessed pre- and post-implantation. The mean age was 81+/-7 years and the mean Logistic Euroscore was 20+/-12. Following PAVR, the mean transaortic valve gradient decreased (46+/-16 mmHg pre-treatment vs. 12+/-7 mmHg post-treatment vs. 9+/-5 mmHg post-discharge, p<0.001) and the mean effective orifice area increased (0.75+/-0.23 cm2 pre-treatment vs. 1.97+/-0.85 cm2 post-treatment vs. 1.72+/-0.45 cm2 post-discharge, p<0.001). There was no significant change in mean ejection fraction (41+/-12% pre-treatment vs. 46+/-15% post-treatment vs. 44+/-13% post-discharge, p=0.44). Approximately two-thirds of patients had no change in diastolic function at follow-up. CONCLUSION: Following implantation, there was a sustained decrease in aortic valve gradient and increase in aortic valve area. In addition, the mean ejection fraction did not change significantly and in the majority of patients, diastolic function was unchanged.

Early and persistent intraventricular conduction abnormalities and requirements for pacemaking after percutaneous replacement of the aortic valve.

OBJECTIVES: In this retrospective study, we examined the incidence of post-procedural conduction abnormalities and the need for pacing in patients undergoing percutaneous implantation of the aortic valve. BACKGROUND: Safety and feasibility studies have suggested anecdotally the occurrence of conduction abnormalities and requirements for pacing after percutaneous implantation of the aortic valve. METHODS: We examined the standard 12-lead electrocardiograms (ECGs) of 40 consecutive patients in whom a CoreValve Revalving System (CoreValve, Paris, France) was implanted between November 2005 and March 2008. We examined the 12-lead ECG before treatment, after treatment, and at 1-month follow-up. We documented the requirements for temporary or permanent pacemaking. RESULTS: The mean age of patients was 82 +/- 7 years. Post-procedural mortality at 72 h was 0%. There was a significant increase in the frequency of left bundle branch block (LBBB) after percutaneous aortic valve replacement (15% before treatment vs. 55% after treatment, p = 0.001). Although the incidence of LBBB had decreased after follow-up of 1 month, it did not reach statistical significance, with the proportion decreasing from 55% to 48% (p = 0.63). The only 2 patients with pre-treatment right bundle branch block became dependent on temporary pacing immediately after valve implantation and subsequently needed permanent pacing. A temporary and permanent pacemaker was required in 20% and 18% of patients, respectively. CONCLUSIONS: In this study, there was a significant increase in the frequency of LBBB after percutaneous insertion of the aortic valvar prosthesis. Patients with pre-existing right bundle branch block may be at risk for the development of complete heart block and subsequent need for pacing.

Coronary collateral circulation: the effects of smoking and alcohol.

OBJECTIVE: The presence or absence of coronary collaterals is of vital importance during acute ischemia. Smoking and alcohol have been suggested to play a role, but data are scarce. We examined the extent to which smoking and alcohol use affect the presence of coronary collateral circulation. METHODS: Cross-sectional study in 242 patients, admitted for elective PTCA. Smoking was defined as past or current. Pack years were calculated and categorized into never-smokers (reference-category): <10, 10-19, 20-29, and >or=30 pack years. Alcohol consumption was defined as past or current, and categorized into never-users (reference-category): <1, 1-10, 11-20, and >or=21 units per week (UPW). Collaterals were graded with Rentrop's classification. Coronary collateral presence was defined as Rentrop-grade >or=1. RESULTS: Current smoking (odds ratio (OR) 4.17; 95% confidence interval (CI) 1.79-9.71) was positively associated, while pack years of smoking was not related. Current alcohol intake showed a J-shaped tendency with coronary collateral presence, while past moderate alcohol consumption was inversely associated (OR 0.19; 95% CI 0.04-0.98). CONCLUSIONS: Smoking and (to some extent) alcohol use are associated with collateral presence. The results support the view that life-style factors may affect the formation of coronary collaterals in patients with ischemic cardiac disease.

Cardiac ischemic score determines the presence of coronary collateral circulation.

PURPOSE: The presence of coronary collaterals is of vital importance during acute ischemia, however, marked interindividual variability exists. We examined the extent to which the burden of cardiac ischemia, expressed as a cardiac ischemic score, affects coronary collateral presence. METHODS: Cross-sectional study in 244 patients, admitted for elective coronary angioplasty. Collaterals were graded with Rentrop's classification. Coronary collateral presence was defined as Rentrop-grade > or =1. The cardiac ischemic score (range 0-4) was calculated by adding 1 point for each of the following four clinical factors present: angina pectoris on exertion, angina pectoris during emotions, previous myocardial infarction, and previous coronary intervention. These four clinical factors were chosen because they can be easily assessed in every patient. We used logistic regression with adjustment for gender, age, hypertension, diabetes mellitus, and hyperlipidemia. RESULTS: The extent of the cardiac ischemic score (odds ratio 1.8 per score-point; 95% confidence interval 1.3-2.5) was strongly associated with coronary collateral presence. Additional adjustment for multivessel coronary disease left the relation essentially unchanged. Also, if the definition of collateral presence was limited to Rentrop-grade 2 and 3, results were effectively the same. CONCLUSION: The extent of the cardiac ischemic score determines the presence of coronary collaterals, and may provide a new index for simple assessment of collateral vascular development.

Presence of the metabolic syndrome does not impair coronary collateral vessel formation in patients with documented coronary artery disease.

OBJECTIVE: The metabolic syndrome confers an increased risk for cardiovascular morbidity and mortality. The presence of coronary collaterals may have beneficial effects during myocardial ischemia and may improve cardiovascular outcome in patients with coronary artery disease. Impaired collateral formation could be one of the reasons for the increased cardiovascular risk in patients with the metabolic syndrome. The aim of the present study was to determine the influence of the metabolic syndrome and insulin resistance on the presence of coronary collaterals. RESEARCH DESIGNS AND METHODS: We conducted a cross-sectional study in 227 patients referred for elective percutaneous transluminal coronary angioplasty to the University Medical Centre Utrecht. The metabolic syndrome was diagnosed according to Adult Treatment Panel III, and homeostasis model assessment of insulin resistance (HOMA-IR) and quantitative insulin sensitivity check index (QUICKI) were used to quantify insulin resistance. Coronary collaterals were graded with Rentrop's classification. Rentrop grade >/=1 indicated the presence of collaterals. Results were adjusted for age, sex, and severity of coronary artery disease. RESULTS: A total of 103 patients (45%) were diagnosed with the metabolic syndrome. There was no association between the metabolic syndrome and the presence of coronary collateral formation (odds ratio [OR] 1.2 [95% CI 0.7-2.0]). Also, the degree of insulin resistance was not related to the presence of coronary collaterals. The OR for HOMA-IR (highest versus lowest tertile) was 0.7 (0.3-1.5) and for QUICKI (lowest versus highest tertile) 0.8 (0.4-1.6). CONCLUSIONS: The metabolic syndrome and insulin resistance are not related to the presence of coronary collaterals in patients with documented coronary artery disease.